Cerebrovascular disease in the elderly

Abstract

The signs and symptoms of cerebrovascular insufficiency should be part of the clinical knowledge of all practicing physicians. Patients with clear-cut symptoms of carotid or anterior circulation disorders generally do not pose a diagnostic or therapeutic problem, but patients with nonclassic hemispheric symptoms or symptoms of vertebrobasilar insufficiency often pose diagnostic challenges. From the standpoint of otolaryngologic surgery, symptoms of cerebrovascular insufficiency may mimic symptoms of other types of head and neck disease. A careful history and physical examination usually allow a distinction to be made between cerebrovascular insufficiency and symptoms due to other otolaryngologic diseases. In patients in whom there is a question as to the basis for the symptoms, a variety of noninvasive tests are available that may allow accurate delineation of the correct diagnosis or the proper selection of more invasive testing procedures. Although there have been several large prospective randomized studies evaluating the role of antiplatelet or anticoagulant agents in the management of patients with symptoms of cerebrovascular insufficiency, the exact role of these agents in the prevention of stroke remains controversial. For most patients with symptoms of transient ischemic attack, reversible ischemic neurologic deficit, or stroke with neurologic recovery, carotid endarterectomy remains, in the opinion of the authors, the therapy of choice. Stroke is the third leading cause of death in the United States and results in significant morbidity and cost. Once a permanent neurologic deficit is present, relatively little can be done to effect the return of neurologic function. Unfortunately not all patients present with warning symptoms, but in patients who present with transient neurologic complaints, careful evaluation is mandatory so that we may identify those who are believed to be at risk for stroke. The purpose in this article has been to provide an overview of cerebrovascular disease. We have tried to provide a definition of clinical problems, a general description of the pathophysiology, an explanation of some of the currently available diagnostic techniques, and a brief discussion about the therapeutic modalities. Of necessity, some parts of this presentation have been brief. The interested reader is referred to appropriate bibliographic references for more detail.